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Insights Category: Technical Information

On July 12th at the American Society of Healthcare Engineers (ASHE) annual conference in Denver, CO George Mills, Director of Engineering for the Joint Commission, announced that the Joint Commission will be eliminating the Plan for Improvement (PFI) portion of the Statement of Conditions (SOC) starting August 1st. See the announcement from ASHE Here. Christopher Lynch. P.E., Principal with Code Red Consultants was in attendance at the presentation by George Mills. The list below summarizes some key information regarding this significant change in the compliance process:

  • Why is the change being made? The change is occurring due to a Centers for Medicare and Medicaid Services rule requiring the correction of known life safety code deficiencies within 60 days of discovering them. It is worthy to note that there is a time based waiver process for items which justifiably take longer to correct.
  • What happens to existing PFIs? Starting August 1st, the Joint Commission will no longer be providing life safety surveyors with access to the e-SOC information or the PFI. The PFI is now an internal tool to help facilities manage their deficiencies. There is no obligation for a facility to provide their known deficiencies to the surveyors when they arrive. Under the previous PFI process, facilities were not cited for deficiencies they proactively reported through the PFI. This is no longer the case and the Joint Commission will be employing a “See it, Cite it” approach.
  • What happens if I receive citations during a survey? The facility will have 60 days to correct identified deficiencies noted during the survey. This will be done through what is called a Survey Plan For Improvement or SPFI.
  • What do I do if I need more than 60 days to correct an item that is cited during a survey? If more than 60 days is needed, the facility has 45 days from the time the finding is made to submit a time limited waiver request through the Joint Commissions Salesforce portal. After submitting the request, the facility will receive a receipt that should be saved as evidence that the request is in the queue. The time limited waiver will be evaluated and approved by CMS.

These changes are substantial and eliminate the protection previously afforded to facilities which proactively identified issues and corrected them on a timeline they created. The elimination of the PFI process will lead many facilities to re-evaluate how they assess their facility for life safety code deficiencies. While there is no longer any protection for proactively identifying issues, the pain facilities will feel if they are identified on survey has been elevated. There is a time based waiver process, however those are evaluated on a case by case basis by CMS and there is no guarantee additional time will be allotted.

Our recommendation is for facilities to evaluate the timing of when they perform life safety evaluations of their facilities. The new system post August 1 will incentivize facilities to have all known deficiencies corrected. We believe this will drive facilities to perform evaluations annually rather than every three years such that the timing and resources needed to correct items can be accommodated before the next Joint Commission inspection. In addition to annual inspections, an additional evaluation in the months preceding an inspection would be advantageous to evaluate compliance of common maintenance items such as fire doors. Mr. Mills made an excellent point during his presentation that it would be wise for facilities to still utilize the PFI tool on the Joint Commission web site to keep the issues visible to hospital leadership to ensure sufficient budgets and resources can be allocated to performing corrective actions.

There will be more information to come on this topic before August 1st, but please feel free to contact us to discuss impacts on your facilities and life safety program.

With the recent adoption of a new state fire code, Massachusetts building owners and property managers need to understand how NFPA 241 applies to their ongoing construction projects. It is the owner’s responsibility to manage the construction fire safety program, whether you are managing a 5,000 SF tenant improvement project or you are developing a new high-rise residential tower. If you have questions about what this means to you, your property, or your project, then you should come join the Boston Fire Department, Boston ISD, Code Red Consultants, and a panel of experts at an upcoming industry event sponsored by the AGC of MA.

Register here for the April 7th event at the Seaport Hotel in Boston, MA.

http://www.agcmass.org/ev_calendar_day.asp?date=4/7/2016&eventid=86

Q: Are separate plumbing fixtures required to be provided for staff and student occupants in educational occupancies?

A: Yes, in accordance with 248 CMR Section 10.10(18)(h)(4):

Q: Are colleges and other higher education buildings considered as “educational” for the purposes of determining plumbing fixture requirements?

A: Yes. For the most part there is general alignment between the occupancy classifications of the building code and the plumbing code in Massachusetts. However, the classification of college buildings will vary between the two:

Plumbing Code: College, University, Higher Education are considered as “Educational” per 248 CMR Section 10.10(18)(h) & Table 1:

Note that the plumbing code classification as “Educational” in colleges is typically reserved for buildings where teaching/lecturing is occurring. For other buildings the plumbing code classifications may be in closer agreement with the building code. For example, a library would be “Assembly”, or a staff office building would be “Office”. In these instances, separate fixtures would not be expected unless teaching/lecture functions were expected.

Building Code: College, University, other Education above the 12th Grade are considered as “Group B, Business” per 780 CMR Section 304.1:

With Massachusetts’ recent adoption of NFPA 1 as part of the new State Fire Code, each construction project a specific NFPA 241 Construction Fire Safety Program. The owner, general contractor(s), and the subcontractors each play an integral role in demonstrating compliance; from proper documentation to collaborative implementation.

NFPA 241 Section 7.2 outlines the owner’s responsibility for fire protection in a building under construction; “The owner shall designate a person who shall be responsible for the fire prevention program and who shall ensure that it is carried out to completion…The fire prevention program manager shall have the authority to enforce the provisions of this and other applicable fire protection standards.” As such, building owners should minimally be responsible for the following:

  1. Assign Fire Protection Program Manager (FPPM) and Alternate
    This individual will be responsible for the enforcement and implementation of the building/campus NFPA 241 Plan and serve as the point of contact for any first responders.
  2. Develop, Manage, and Implement Master Building/Campus NFPA 241 Program
    Provides baseline approach to fire protection and life safety for building. This is used/referenced by current and future construction projects. Depending on complexity, assistance from a fire consultant may be necessary.
  3. Confirm General Contractors and their Subcontractors are developing/implementing their respective Project Level NFPA 241 Plans and Impairment Plans.
  4. Coordinate all impairments on site.
  5. Property Maintenance
  • Fire alarm / Fire Protection / Secondary Power
  • *Smoke Control (most commonly overlooked)
  • Semi-annual testing / Maintenance schedule available on site / Proof of performance and functional criteria are satisfied.
  • Fire Drills / Evacuation Plans

General Contractor’s Role

All GC’s working in the building will be required to issue an independent, Project-Level NFPA 241 Plan for each individual project. Said Plan should reference and incorporate the policies and procedures included in this Program, while speaking to specific fire protection, life safety, and safeguards that are appropriate for the scope of work at hand.

8th Edition 780 CMR

The current Massachusetts State Building Code (8th Edition; also known as 780 CMR) is an amended version of the 2009 International Building Code (IBC). The base 2009 IBC code introduced a new requirement for a fire service access elevator (FSAE) in buildings with an occupied floor more than 120 feet above the lowest level of fire department vehicle access (780 CMR 403.6.1). Massachusetts amended Section 403.6.1 to require a FSAE in buildings more than 70 feet in height above grade plane such that FSAE are required in all hi-rise buildings. In order to serve as the FSAE, an elevator must satisfy the following conditions (780 CMR 3007):

  • The FSAE must serve every floor of the building;
  • The FSAE must be open to a lobby that is:
    • 150 square foot& minimum with an 8-foot minimum dimension on every floor except the street floor.
    • Enclosed by 1-hour smoke barriers with 3/4 –hour doors.
    • Provided with direct access to an exit enclosure.
  • A Class I standpipe hose connection must be provided in the exit enclosure having direct access from the FSAE lobby;
  • FSAE must be continuously monitored at the fire command center; and
  • Normal and standby power must be provided in accordance with 780 CMR Chapters 27 & 30

9th Edition 780 CMR

The 9th Edition 780 CMR is an amended version of the 2015 IBC. For further information about the adoption date of the 9th Edition 780 CMR, applicable codes, and the code adoption process please see Code Red Consultants Blog Post titled Building Code by Chris Lizewski.

The 2015 IBC, and thus 9th Edition 780 CMR, significantly changes the requirements related to FSAEs. The 2015 IBC base code requires that in buildings with an occupied floor more than 120 feet above the lowest level of fire department vehicle access, no fewer than two fire service access elevators, or all elevators, whichever is less, be provided. Additionally, it is important to note the draft amendments for public review do not amend IBC Section 403.6.1 as was done for the 8th Edition 780 CMR. The impact of this code change is twofold in that buildings less than 120 feet in height above the lowest level of fire department vehicle access no longer require a FSAE; however, buildings exceeding this threshold now need two FSAE instead of one. It is important that this code change be considered early in design based on the considerable impact on building core configuration.

In addition to the above code change, the 2015 IBC also introduces the following notable changes:

  • Under the 8th Edition 780 CMR it was required that a Class I standpipe hose connection be provided in the exit enclosure having direct access from the FSAE lobby. This requirement has been updated such that the exit enclosure containing the standpipe must have access to the floor without passing through the fire service access elevator lobby. A change was made to this requirement in order to prevent the passage of smoke from the floor to the FSAE lobby and hoistway when firefighters run hoses from the standpipe to the floor (2015 IBC 3007.9.1).
  • Access to not less than one of the required exits from the floor must be provided without travel through enclosed elevator lobbies (2015 IBC 1016.2)
  • A pictorial symbol designating which elevators are fire service access elevators must be installed on both sides of the hoistway door (2015 IBC 3007.6.5).

Continue to monitor the Code Red Consultants Blog for updates relating to the proposed timeline of the 9th Edition 780 CMR code adoption and any proposed changes to the FSAE.

When is a Special Inspector required?

  • New smoke control systems designed to comply with IBC Section 909 are required to be tested by a Special Inspector (IBC Section 909.18.8.1).
  • Existing smoke control systems where the original design has been altered or where new smoke control equipment is installed may also require a smoke control Special Inspector as determined by the local AHJ.
  • Smoke control systems subject to the requirements of IBC Section 909 include any of the following active or passive systems:

•  Atrium smoke exhaust systems
•  Stairwell pressurization
•  Smokeproof enclosures (ventilated vestibules)
•  Elevator pressurization
•  Zone smoke control systems
•  Underground buildings
•  Use Group I-3 windowless buildings

Who can serve as a Special Inspector?

  • The Special Inspector is required to have expertise in fire protection engineering, mechanical engineering and certification as air balancers (IBC Section 909.18.8.2). It is not uncommon for the Special Inspector to consist of a team of individuals capable of satisfying the requirements for engineering expertise and air balancer certification.

When should the smoke control Special Inspector get involved?

  • It is recommended that the smoke control Special Inspector get involved during the design process. The Special Inspector can provide a review of the design with an eye towards properly integrating the many building components that make up a smoke control design.

When is special inspection testing required to be performed?

  • Duct leakage testing is required to be performed prior to the concealment of ductwork (IBC Section 909.18.1(1))
  • Prior to occupancy and after sufficient completion, testing of pressure differentials, flow measurements, and detection and control verification is required (IBC Section 909.18.8.1(2))

What documentation is required to be prepared by the Special Inspector?

  • The Special Inspector is required to prepare a complete testing report that is reviewed, signed and sealed by a registered design professional. A copy of the final report is required to be filed with the fire code official and a copy is required to be maintained in an approved location within the building (IBC Section 909.18.8.3.1).The report is required to include the following:

•  Identification of all devices by manufacturer
•  Nameplate data
•  Design Values
•  Measured Values

Given the adoption of the new MA State Comprehensive Fire Code earlier this year, ever increasing attention is being paid to construction fire safety in the context of NFPA 241, Standard for Safeguarding Construction, Alteration, and Demolition Operations.

Code Red Consultants has been assisting construction and ownership teams in understanding and applying NFPA 241 by means of the development of NFPA 241 Construction Fire Safety Programs; with one such plan being developed for the marquee Millennium Tower Project.

Assisted by this plan, Suffolk Construction has been able to seamlessly transition their existing construction fire safety practices to address the requirements of NFPA 241, while keeping their project and site safe for abutters, constructors, and responding personnel.

While the terminology may be similar, the code does not actually link the occupancy classification of a building or space to the applicable occupant load factor for means of egress design requirements. This is a common misconception we see many designers make that can have a significant impact on the required number or size of exits in a building. When determining the occupant loads for your facility’s egress requirements, it is important to consider the difference between the occupancy classification of the building, and function of the space for the area you are evaluating.

  • Occupancy Classification – based on a building’s use and purpose as determined by Chapter 3 of the International Building Code (IBC). This classification (or several if the facility is a mixed occupancy) is applied throughout all areas of a building.
  • Occupant Load – based on the “function of space”, which is defined independently of the building’s occupancy classification.

While in most cases, the occupancy classification of a building or space aligns with its intended function, this is not always the case. For example, in a typical office building, the office space and any small conference/meeting rooms with less than 50 people will be classified as a Group B Business Occupancy (IBC 303.1, 304.1). However, the function of space for the small conference/meeting rooms align themselves most closely with “assembly without fixed seats, unconcentrated (tables and chairs)” in IBC Table 1004.1.1 and should be loaded with the corresponding occupant load factor accordingly. When calculating the occupant load factor for the conference/meeting rooms, 15 net square feet per occupant should be applied. Often times, we see designers loading these spaces at 100 gross square feet per occupant for “business areas” since they are defined as Group B Occupancies, however this is not technically correct and can have a significant impact on egress design. We often get asked if this same approach would apply to a “breakout” space that, while looking very similar to the conference room described above, differs in that its intended to only act as collaboration space for employees sitting in adjacent cubicles/offices. While the language in the IBC does not directly address this distinction, we often find in practice that the building official is accepting of utilizing an occupant load factor of 100 gross square feet for this type of breakout space if it can be illustrated that it is in-fact a non-simultaneous use with the surrounding offices. This is just one small facet of occupant loads. Stay tuned for Part II which will address the difference between net and gross calculations.

Joint Commission Releases 2014 Top Citations Update Every 6 months or so, the Joint Commission publishes lists of the top citations across the various types of health facilities it accredits. The top 10 citations for the first half of 2014 were recently released, and not surprisingly, fire protection/life safety deficiencies continued to dominate the list. The top 10 citations and some of our thoughts are provided below:

  1. 53% – EC.02.05.01: The hospital manages risks associated with its utility systems.
    This citation includes issues related to inadequate utility systems design or function and jumped from #10 in 2013 to #1 this year. With a strong focus on infectious disease prevention and control, it should come as no surprise that the surveyors are taking a close look to make sure facilities are properly inspecting, testing, and maintaining all of their utility systems, as well as checking for appropriate pressure relationships between sterile and dirty areas.
  2. 52% – LS.02.01.20: The hospital maintains the integrity of the means of egress.
    Maintaining the integrity of the means of egress always seems to fall at the top of the list as facility managers’ struggle with policing corridor clutter and keeping egress paths clear. A few useful thoughts to help manage corridor clutter:

    1. Egress corridors more than 8 feet in width can partitioned off to store computers and equipment within alcoves.
    2. Dead end corridors beyond an egress stairwell can be used to store equipment less than 50 feet in area.
    3. Suites, as identified on your life safety plans, are considered as groups of rooms and not corridors, and may be used to store equipment within hallways provided that at least 44 inches of clearance is maintained.
    4. Facilities may elect to use the waiver permitted under CMS S&C-12-21 to utilize the 2012 NFPA 101 provisions which allow projections into corridors for wheeled equipment and fixed furniture under certain circumstances. The waiver election must be documented, noted in the Additional Comments section of the BBI, and brought to the attention of surveyors upon arriving on-site.
  3. 51% – EC.02.06.01: The hospital establishes and maintains a safe, functional
    A common deficiency under EC.02.06.01 that has been popping up lately is that all safety showers, eye wash stations, and drench hoses are tested per ANSI, OSHA, Joint Commission, and other requirements as indicated in the hospital policy. What does this mean?

    1. Use a risk assessment to determine placement of showers and eye washes. 
    2. Providing a testing policy which specifies test intervals (weekly expected). 
    3. Document all test results. 
    4. Ensure the water is tepid between 60°F – 100°F.

    Other issues that commonly plague hospitals include unsecured oxygen cylinders (see our blog post here), and inadequate ventilation, temperature, and humidity levels within the facility.

  4. 50% – EC.02.03.05: The hospital maintains fire safety equipment and fire safety building features.
    Having organized, well-documented inspection and testing reports for your fire protection and life safety equipment and systems is critical. Challenges continue to revolve around facilities holding contractors accountable to provide timely documentation that indicates full compliance with the required standard. Providing follow up documentation that deficiencies from punch lists, work orders, or failed system testing are also commonly overlooked and must be documented to illustrate full compliance. Some best practices include adding applicable code editions and references on all sheets, and cross-referencing test report with corrective work orders.
  5. 50% – IC.02.02.01: The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
  6. 49% – LS.02.01.10: Building and fire protection features are designed and maintained to minimize the efforts of fire, smoke, and heat.
    In nearly half of all hospitals, the life safety surveyors continue to cite facilities for problems related to fire/smoke barrier management including penetrations, fire doors, and damper issues. Unsealed penetrations and fire doors with no labels and excessive undercut and gaps continue to be issues for facility managers to stay on top of. Be aware: combustible foam is not a UL-Listed firestop assembly and cannot be used to seal penetrations. While the product may state UL approved for “fireblocking” this is intended for residential use, and is not appropriate for firestopping.
  7. 49% – RC.01.01.01: The hospital maintains complete and accurate medical records for each individual patient
  8. 46% – LS.02.01.30: The hospital provides and maintains building features to protect individuals from the hazardous of fire and smoke.
    Another key issue is maintaining building features is providing accurate, up-to-date life safety plans. Minimally, the life safety plans should illustrate:

    1. Fire safety features
    2. Areas of the building that are sprinklered/unsprinklered
    3. Hazardous storage areas 
    4. Fire/smoke barriers 
    5. Suite boundaries, including sizes and types 
    6. Smoke compartments, including locations and sizes 
    7. Chutes and shaft enclosures 
    8. Any approved equivalencies or waivers
  9. 44% – LS.02.01.35: The hospital provides and maintains systems for extinguishing fires.
    One of the most common issues we see here is maintaining the 18” clearance beneath sprinklers within a storage area. Note that perimeter shelving above the 18” line is permitted unless located directly beneath a sprinkler.
  10. 36% – EC.02.02.01: The hospital manages risks related to hazardous materials and waste.

One of the most frequent topics we receive questions on is existing building code requirements. There is often a lot of confusion for commercial construction projects in existing buildings relative to what upgrades will be triggered by the planned scope of work, if any. In our opinion, answering that question requires experience and an in-depth understanding of the requirements and scoping language for existing buildings. Here are a few of the most common questions we receive:

What requirements govern commercial construction projects in existing buildings in Massachusetts?

The Massachusetts State Building Code 8th Edition (780 CMR) is an amended version of the 2009 International Building Code (IBC). Within the Massachusetts amendments to the 2009 IBC, Section 3401.1 deletes Chapter 34 Existing Structures in its entirety and replaces it with the International Existing Building Code (IEBC), 2009 Edition, with Massachusetts amendments. This amended version of the International Existing Building Code is referred to as the Existing Building Code of Massachusetts.

This code governs repairs, renovations, alterations, changes in use, and additions to existing buildings including those that are historic.

It is also helpful to know that there are additional existing building scoping requirements contained in Section 102.6 of 780 CMR. These requirements outline the general philosophy the code takes with existing buildings that were originally constructed under previous codes and have been legally occupied. These scoping requirements provide a clarity on fundamental understandings relative to previously approved existing conditions, safety features which may no longer be required in the new code, and minimum levels of safety for egress, lighting and ventilation.

Accessibility requirements to public areas in buildings are covered by 521 CMR, the Massachusetts Architectural Access Board requirements. All of the accessibility requirements within the Massachusetts Existing Building Code have been deleted and replaced with a reference to 521 CMR. It should be noted that 521 CMR has a different set of scoping requirements that are unique to that code.

Where can I find the Massachusetts amendments to the 2009 International Existing Building Code?

The Massachusetts Board of Building Regulations and Standards (BBRS) website contains electronic copies of the amendments. They can be found at the following link: Link to Massachusetts Amendments. The applicable version of the Massachusetts amendments is located in the amendment section of the web site and are dated 6-20-2014. Please note that electronic versions of the building code posted on this website are not official. Official copies must be purchased from the state bookstore. Additionally, there is a helpful official interpretation issued by the BBRS on certain applications of the Massachusetts Existing Building Code requirements that can be found at the following link: BBRS Official Interpretations.

How do I use the Massachusetts Amendments with the base 2009 IBC or 2009 IEBC?

The BBRS recommends the following process when evaluating code compliance in accordance with 780 CMR, the Massachusetts State Building Code:

  1. Find the topic in the base code (either the 2009 IBC or 2009 IEBC)
  2. Check the Massachusetts amendments to either document to see if the base language is changed in anyway under the “8th Edition Base Volume” link on the BBRS website.
  3. Check to see if any subsequent changes to the 8th Edition base volume has occurred by looking under the “Check Amendments since August 2010” portion of the BBRS web site.

A building official requested a Chapter 34 report or existing building code analysis. What do I need to include?

First, if your project is a simple repair, it may not even require a permit. Section 105.2 of 780 CMR outlines the types of repair work that are exempt from permit. These include cosmetic upgrades such as painting, carpeting, tiling, and similar finish work.

If your work does require a permit, Section 101.5.4.0 of the Massachusetts Existing Building Code states that the code official can request an investigation and evaluation of the existing building in accordance with the provisions of this code. There is no specific form that needs to be filled out to document this analysis. The level of analysis needed will vary depending on the scope of the project and the condition of the existing building. The investigation and evaluation is required to minimally document the effects of the proposed work on at least the structural, means of egress, fire protection, energy conservation, lighting, hazardous materials, and ventilation for the space under consideration and potentially the entire building if impacted by the proposed work. The results of this analysis are required to be submitted to the building official in written form.

The analysis should also indicate the compliance method that is used to perform the evaluation. The Massachusetts Existing Building Code contains three different compliance options:

  1. The Prescriptive Compliance Method contained in Chapter 3
  2. The Work Area Compliance Method contained in Chapter 4-12
  3. The Performance Compliance Method contained in Chapter 13

For each permit, only 1 compliance method is allowed to be used. If you select to use the Work Area methodology you are permitted to identify multiple scopes of work (i.e. Level 1 Alteration and Repair) on the same permit.

Who can prepare an existing building code analysis?

780 CMR and the Massachusetts Existing Building Code do not outline a set of minimum credentials to prepare this investigation and analysis. Most often it is a registered design professional, such as an architect, engineer, code consultant, or some combination thereof.

What compliance methodology should I use?

Answering this question really requires an understanding of the planned project and the condition of the existing building. We have tried to outline, in general, the conditions when we recommend use of each of the compliance methodologies:

  1. Prescriptive Compliance Method: This methodology is based on outlining scoping criteria for different types of work (i.e. addition, alteration, change in use, etc.). It follows the general philosophy that new work should meet new construction requirements and existing previously approved conditions can remain. There is not language that addresses specific applications, so it leaves the application of the scoping criteria up to interpretation. We find this methodology most useful on projects in relatively new buildings that are generally code compliant, small projects with very limited scope, or substantial renovation projects where the substantial replacement of the interior of the building is being replaced.
  2. Work Area Compliance Method: This methodology is based on first defining the classification of the work to be performed and the “work area”. The definition of “work area” should be reviewed, as it specific to reconfigured space. The aforementioned BBRS interpretations provide a useful example of how to determine the “Work Area”. Unlike the Prescriptive Compliance Method, this methodology has more specific language for certain applications, which can help limit room for differing interpretations on when retroactive upgrades are required. We find this methodology most useful where there is a significant renovation project to a portion of the building, with portions of the existing building remaining unaltered.
  3. Performance Compliance Method: This methodology is a scoring system. Positive points are given to safety features and negative points are given to deficient conditions. A passing score is needed for the approach to be acceptable. This methodology is most useful where there is a known deficient condition with one system that will remain that is offset by other safety features that may exceed the minimum code requirements. For instance, work occurring within an existing building which has various shafts which are not enclosed in fire rated construction, but the building does have a compliant sprinkler system and fire alarm/detection system. This method may be useful to use if it is impractical to upgrade the construction of the shafts within the building. We find this methodology to be used much less in practice when compared with the Prescriptive or Work Area methodologies, however is a valuable tool to have in your back pocket on existing buildings with unique or challenging circumstances.

As you can tell from the questions above, the Massachusetts Existing Building Code can be a puzzling and intimidating document to navigate. Knowing where to begin and the various options available is a critical first step in making sure your next existing building project gets off on the right foot.